Provider Demographics
NPI:1639342843
Name:WILLOWS AT WORCESTER LLC
Entity Type:Organization
Organization Name:WILLOWS AT WORCESTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:
Authorized Official - Last Name:SACON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:508-898-3490
Mailing Address - Street 1:101 BARRY RD
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01609-1154
Mailing Address - Country:US
Mailing Address - Phone:508-798-3727
Mailing Address - Fax:
Practice Address - Street 1:101 BARRY RD
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01609-1154
Practice Address - Country:US
Practice Address - Phone:508-798-3727
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-09
Last Update Date:2012-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA5503329Medicaid